Managing Fee-For-Service Billing Claim Refusals

When a FFS billing claim is refused, it can be both frustrating and time-consuming to address.

Learn about the essential steps to efficiently manage and resolve denied claims. Streamline your process, minimize delays, and enhance your billing outcomes.

• Review the 2-digit MSP Explanatory Code.
• Most Electronic Medical Records Systems (EMRs) will display the Explanatory Code, and the description of why the claims are being refused.
• For questions about your claim or MSP Explanatory Code, contact provider support at:
  • Lower Mainland: +1 604 456-6950
  • The rest of BC: +1 866 456-6950 

About Explanatory Codes

When a FFS billing claim is refused by MSP via Teleplan, a corresponding two-digit code, known as the Explanatory Code, is assigned to each claim. A full list of all Explanatory Codes can be found on the Ministry website.

Each Explanatory Code is associated with a specific rationale for the refused claim. For example, if the billing claim is refused for 'AA – PHN because the patient’s PHN is missing or invalid', it is recommended to re-check that the patient’s PHN has been entered correctly within your EMR and billing field.

 

• Check all billing fields within your EMR billing claim for accuracy.
• Double-check if the date of service is correct.
• Check if start/end times are required.
• Review the Service Location Codes.
• Review the ICD-9 Diagnostic code(s).
• Ensure there is an “adequate medical record” for the billed services in the patient’s medical record.

Billing claim formatting

After reviewing the Explanatory Code, correct the billing claim in your EMR billing field with the information from the code.

For example, if the Explanatory Code is 'CF—Time service was rendered is missing or invalid', the billing claim should be reviewed to ensure that the time has been entered correctly. 

Reminder: When entering times, utilize the 24-hour HHMM format, where 0000 represents 12:00 A.M, midnight.

It is important to note that some billing fields may be tied to incentives and should be reviewed on each claim. These fields may include:

• Facility number for Business Cost Premium
• Rural Retention indicator

From a billing and audit perspective, this may also be a good opportunity to ensure that an “adequate medical record” has been recorded and maintained. As referenced in the Medical Services Commission (MSC) Payment Schedule and General Preamble, C.10, “What Defines an ‘Adequate Medical Record’,” and A.2: “Introduction to the General Preamble” under note vii): "making and maintaining an adequate medical record of the encounter that appropriately supports the service being claimed is essential. A service for which an adequate medical record has not been recorded and retained is considered incomplete and not a benefit under the Plan."

 

If a billing claim is refused, it may be due to missing or improperly submitted information that is required. Review the following:

• Review the MSC Payment Schedule for limits, billing, and eligibility criteria related to the submitted fee code.
• Ensure that the service(s) billed are an insured benefit under the MSP.
• Ensure that the correct fee code for the service(s) being claimed.
• Check if the service(s) are included in another fee code that has also been billed.

Information about fee codes

It is recommended to review the Doctors of BC Fee Guide that mirrors the MSC Payment Schedule regularly to ensure that the requirements of the fee codes have not changed. If a billing claim is refused, one or more of the required pieces of information may not have been submitted properly to MSP. Review the MSC Payment Schedule and General Preamble to ensure the appropriate fee code is billed for the service(s) submitted to MSP.

The MSC maintains records of fee code changes for quick review and tracking. These records are on the same page as the MSC Payment Schedule. More updates are sent in the form of broadcast messages also sent to your EMR via Teleplan at the time of implementation. All current broadcast messages are also available on the Doctors of BC MSP Broadcast Messages Index.

Note: If no applicable fee code exists for the services provided, you can bill a miscellaneous fee code (***99) as per the MSC Payment Schedule located in the General Preamble: C.4 Miscellaneous Services.

To discuss amendments or the creation of a new fee code, you should contact your section representative. For more information on the process for making changes to the MSC Payment Schedule / Doctors of BC Fee Guide, please contact our Fee Guide Advisors at: economics@doctorsofbc.ca.

 

• If there was an error when initially entering the billing information, you can update the billing claim with the correct information.
• When applicable, add a brief note or comment in the billing field of your Electronic Medical Record (EMR) for MSP.

Details about modifying billing claims

After reviewing the Explanatory Code and fee code, address the issue in the billing claim field. Update the claim with the correct information to resolve the reason in the Explanatory Code. If the fee code is incorrect, change it to the correct one.

Additional information can be provided to the Medical Services Plan (MSP) within the EMR billing field, if required.

Note: Due to the EMR note character limit, longer notes may be truncated. For extended explanations or rationale, please fax the additional information (e.g., OR report, consult) to MSP billing support at Fax: 250 405-3593. Providing additional information to MSP regarding your claim may expedite their review of your billing and payment of your claim.

 

• If your claim is over 90 days from the date of service, submission code X must be entered in the correct EMR billing field, prior to submission, or the claim may be rejected. See MOA Billing Guide module: 7 Submission Codes.
• Once the billing claim has been adjusted for corrections, it is ready to be resubmitted to MSP for re-adjudication. Follow your EMR vendor’s instructions for resubmission.
• If you have followed all the recommended steps above regarding your billing rejections and are still experiencing issues, please contact our Fee Guide Advisors at: economics@doctorsofbc.ca.